Every finding on record at Willow Springs Hospice Care

Upon patient record review 1 of 5 (Patient #4) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #4: Start of Care was Sunday 10/9/23 with initial POC frequency order of 1x/wk. The first HA visit was made Monday10/17/22. Verified with Administrator that visit week is Sunday-Saturday.

Upon patient client record review, 1 of 5 (Patient #1) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #1: Height 5'1" and weight 170 lbs recorded on Referral Intake, Comprehensive Assessment and MD Face to Face Encounter documentation. The Rx profile has Height of 5'6" and 135 lbs. All are start of care documents dated 6/8/23.

Upon observation, there was no evidence that when the hospice provides durable medical equipment under contract, then the DMEPOS provider is accredited by a CMS approved accreditation organization. The accreditation certificate for the DME provider was not provided prior to end of survey.